Worcestershire Guidelines for Primary Care Antimicrobial Prescribing

Transcription

1 Worcestershire Guidelines for Primary Care Antimicrobial Prescribing Fifth Edition v.5 Updated February 2018 Review date: October 2018 Always consider if antibiotic treatment is necessary Prescribing antibiotics for viral or mild self-limiting infections such as coughs and colds is unlikely to improve the course of the illness, puts patients at risk of side effects and encourages further consultations. Antibiotics should be targeted at those patients who are most likely to benefit. The Clinical Knowledge Summaries (CKS) Library contains many patient leaflets that support appropriate use of antibiotics ( ). The Department of Health website gives details of the Public Health campaign and available leaflets. ( 3-PC-Get-well-soon-without-antibiotics1.pdf) 1

2 INTRODUCTION Welcome to the fifth edition of the Primary Care Guidelines for Antimicrobial Prescribing. The review group contains representatives of the key parties concerned with this area. The guide tries to provide a balanced picture and takes into account local sensitivity data, and its biases, likely pathogens, general practitioners (GP) clinical problems at the interface, best prescribing practice, and evidence based medicine and cost effectiveness. The guide includes all the infection problems that GPs commonly encounter, and many sections have two parts - the first page is a quick reference guide to 1st and 2nd choices where appropriate, together with a few help notes [1st line = preferred drug, 2nd line = drug choice if 1st line is ineffective or inappropriate]. The second page gives further details and helpful clinical pieces of information. It is usually divided into 3 sections: common pathogens, clinical details, and precautions. It is intended that the guide is used to promote best practice and equity of practice across the county of Worcestershire, and is to be updated on a regular basis. 2

3 Antibiotic prescribing and stewardship UK Five Year Antimicrobial Resistance Strategy: 2013 to 2018 Department of Health and DEFRA This document identifies the need for good antibiotic stewardship practices as a vital tool to help reduce antimicrobial resistance. Antibiotic stewardship is actively promoted in secondary care as well as primary care. The tool used in secondary care is given below for information. An antimicrobial stewardship alert was issued by NICE in August 2015, reference: Optimising Prescribing in Primary Care It is recognised that GP consultations can often be challenging, particularly when patients expect to receive antibiotics and may be unwilling to accept that they do not need them. Antimicrobial stewardship has been identified as a key priority by the Royal College of General Practitioners (RCGP). There are a number of different prescribing decision aid tools currently available to guide clinicians on prudent prescribing of antimicrobials to reduce risks associated with the inappropriate prescribing and thus also promote both cost and clinical effectiveness. Some of these guidance tools are applicable to primary care settings: TARGET: Treat Antibiotics Responsibly, Guidance and Education Tool (TARGET) and NICHE: Need (for antibiotic), Investigation (cultures for prescribing), Choice (spectrum of antibiotic), How Long (is your prescription for), Evaluate (your patient and prescription. In secondary care a Start Smart then Focus approach is promoted. For the purpose of this guidance it is encouraged that clinicians in both the primary and secondary care settings are aware of the guidance tools in both sectors and therefore acronyms and guidance tools applicable in both primary and secondary care are covered for information and as a reference source within the content of this guidance. TARGET To provide support for GPs in 2012, a GP toolkit Treat Antibiotics Responsibly, Guidance and Education Tool (TARGET) was developed by the then Health Protection Agency (HPA), in collaboration with several other professional bodies The Antimicrobial Stewardship in Primary Care (ASIPC) Collaboration The TARGET antibiotic toolkit can be found on the clinical and research pages of the RCGP website: The toolkit provides training resources, patient information leaflets and audit tools to promote optimal antimicrobial prescribing. 3

4 Patient information leaflets facilitate none prescribing of antibiotics for situations where they are not indicated. The antibiotic management guidance on this website is the HPA (Public Health England) guidelines for the management of infection in Primary Care which is the major reference source for the Worcestershire guidance. NICHE As part of its activities to support European Antibiotic Awareness Day on 18 November 2015, BSAC (British Society for Antimicrobial Chemotherapy) has launched its NICHE campaign offering all prescribers 5 moments to make a difference and prevent antibiotic resistance. NICHE is an electronic poster campaign with its acronym inviting prescribers to consider the following: Need (for antibiotic), Investigation (cultures for prescribing), Choice (spectrum of antibiotic), How Long (is your prescription for) Evaluate (your patient and prescription). Posters are available in pop art, info graphic and diagrammatic formats, with the info graphic version available for both hospital and community settings. Healthcare professionals are encouraged to download and display locally, helping ensure the messages of European Antibiotic Awareness Day reaches as many individuals as possible. Reference: Start Smart then Focus National guidance for secondary care to support evidence-based antimicrobial stewardship published in 2011 and updated in Start Smart is: Do not start antibiotics in the absence of clinical evidence of infection. If there is evidence/suspicion of bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment. Document on drug chart AND in medical notes o Clinical indication o Duration or review date o Route o Dose. Obtain cultures first. Prescribe single dose antibiotics for surgical prophylaxis: where antibiotics have been shown to be effective. Then Focus is: Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and make a clear plan of action o The Antimicrobial Prescribing Decision The Five Antimicrobial Prescribing Decision options are: o Stop o Switch IV to Oral 4

5 o Change o Continue o Outpatient Parenteral Antibiotic Therapy (OPAT) General Guidance Notes When Prescribing Antibiotics: Signs/Symptoms of infection Does the patient have any clinical signs/symptoms of infection? Samples Have appropriate samples been sent off for and taken for sensitivity testing if possible? Co-amoxiclav for COPD should only be prescribed after positive sputum sample testing result. Microbiology Microbiology does the patient have any relevant previous microbiology which may impact on the antimicrobial choice? Known MRSA, ESBL-producing coliforms, previous C.difficile infection? Allergy Does the patient have any relevant previous history of allergy to penicillins, if so what is the nature of the allergy? Refer to page 6 of guideline for further detail on allergies and adverse drug reactions to antibiotics. Is Referral needed? Does the patient require further referral? All patients presenting with pelvic inflammatory disease and/or epididimo-orchitis and at high risk of Sexually Transmitted Disease (STD) should be referred to the Genitourinary Medicine (GUM) clinic for further treatment with intramuscular (IM) ceftriaxone 500mg stat (the IM injection is not administered by GP s) resistance to quinolones is increasing in this patient group and prompt referral is important. Refer to relevant section of guideline for further detail. Timing of the prescription Timing of the prescription can it be delayed? For all acute and self-limiting lower respiratory tract infections the prescription should be delayed and the patient advised to self-treat : refer to individual section of the guideline for further advice on no or delayed/back up prescription strategy. 5

6 Dose Is the prescribed dose of the antibiotic correct according to the patient s renal or hepatic function? Antibiotic durations Information on antibiotic durations has been given in this guidance document where possible. Adverse Drug Reactions Always take a detailed history of any reported allergy to antibiotics so that patients with a true allergy can be identified. The type of reaction should be documented as this has implications for antibiotic choices. Many patients who report that they are allergic only experienced minor symptoms such as gastrointestinal (GI) disturbance. Restricting the choice of antibiotic on the basis of an inaccurate allergy history may result in them receiving sub optimal treatment. Penicillin allergy Nausea, vomiting or diarrhoea do not, by themselves, constitute an allergic reaction. They are NOT a contraindication for penicillin use. Mild/Rash reaction to penicillin Carbapenem antibiotics (ertapenem and meropenem) are the recommended alternatives in a number of infections when the patient reports a rash reaction to penicillin. Cephalosporins (cephalexin, ceftriaxone etc.) can also be used. Anaphylaxis/Angioedema to penicillin An anaphylactic reaction related to histamine release occurs 30-60mins after previous administration of a penicillin, symptoms may include erythema or pruritis, angioedema, hypotension or shock, urticaria, wheezing, rhinitis. An accelerated allergic reaction occurs 1-72hours after previous administration of a penicillin: symptoms may include erythema or pruritis, angioedema, urticaria, wheezing, rhitinitis (particular caution if symptoms include laryngeal oedema). Unknown/uncorroborated history of penicillin allergy For patients who are unable to give a clear history of penicillin allergy history/reaction, please try, where possible, to gain collateral history from relatives or GP records; including antibiotic use history. Patients who have undetermined penicillin allergy, but have previously received and tolerated a cephalosporin, can receive a carbapenem. Only where there is a clear history of anaphylaxis or absolutely no collateral history available should cephaosporins and carbapenems be avoided 6

7 Antibiotic compliance, drug interactions and side effects It is important to impress on patients who receive a prescription for an antibiotic, that they should always complete the full course of treatment, unless they experience side effects or allergy with the agent. If adverse effects are experience the patient should be advised stop the agent in question to return for clinical review, with change of agent if necessary. When prescribing antibiotics consideration must be given to potential drug interactions; refer to the current edition of the BNF or the drug s Summary of Product Characteristics (available at ). Remember female patients may be receiving oral contraceptives from another prescriber. Also always consider if a premenopausal women may be pregnant when prescribing. Always be aware of potential side effects of antibiotics, particularly C.difficile disease. Advice on managing this condition is incorporated within these guidelines and further information is available in the Infection Prevention and Control Guidelines. Clostridium difficile risk Patients who have had repeated and /or prolonged antibiotic courses and have had recent hospital admission are recognised to be at increased risk of developing C. difficile infection. Particular high risk groups include; o Elderly o Renal, Oncology and Haematology patients o Patients with inflammatory bowel conditions o Those on Proton Pump Inhibitors (PPIs) o Patients who have been treated with clindamycin, ciprofloxacin or cephalosporins. If the patient is potentially at risk for C. difficile infection please consider using narrow spectrum agents and avoid coamoxiclav, ciprofloxacin, cephalosporins and clindamycin unless indicated by specific organism/sensitivity results. Where it is not possible to avoid the above high-risk agents, please try, where possible to prescribe as short a course as possible. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase of C.difficile, MRSA and resistant urinary tract infections (UTIs). 7

8 Avoid widespread use of topical antibiotics (especially those agents also available as systemic agents, e.g. fusidic acid) Limit prescribing over the telephone to exceptional cases. Consider no or delayed/back up prescription strategy where possible for upper respiratory tract infections and mild UTIs. Sepsis Management of sepsis in General Practice Sepsis is a medical emergency. It is responsible for 37,000 deaths annually in the United Kingdom and severe sepsis has a fivefold higher mortality than STEMI or stroke. The reliable recognition of sepsis is the responsibility of all health professionals. The campaign in secondary care has increased awareness and helped to structure the management of sepsis once the patient reaches hospital. However, it is essential that sepsis is recognised early for the patient to reach hospital soon enough to avoid serious complication or death. There are significant challenges and barriers to reliable sepsis identification in a Primary Care setting. Sepsis is a complex condition and its presentation variable. GPs will be experienced in assessing need for hospital assessment in patients with probable self-limiting infection: it is not practicable to expect differentiation between uncomplicated viral and bacterial illness in all cases. Patients who are obviously critically ill are likely to be identified without the need for new efforts. However, there are some patients with severe sepsis with less immediately obvious signs of critical illness. Some of this group might be identified earlier with greater awareness and targeted clinical assessment. In light of this the UK Sepsis Trust have developed a clinical tool kit in partnership with the RCGP to facilitate the reliable identification and management of sepsis in the primary care setting. The toolkit is compatible with international guidelines on sepsis management, with the Department of Health s document Start Smart- then Focus, and with guidance on infection management in primary care issued by Public Health England. The General Practice Sepsis Screening and Action Tool is as follows: General Practice Sepsis Screening and Action Tool is available for reference: 8

9 Review Team: Dr Emma Yates: Consultant Microbiologist, WAHT Dr Thekli Gee: Consultant Microbiologist, WAHT Dr Sumit Bhaduri: Consultant in Genito-urinary Medicine, WHC NHS Trust Priti Patel: Medicines Commissioning Support Pharmacist, SWCCG Carole Clive: Nurse Consultant in Infection Prevention and Control, WHC NHS Trust Review date: October [Ratified by the Area Prescribing Committee (APC)] Electronic updates will be issued as required. Expiry date: 30 th October 2018 Disclaimer: Whilst every effort has been made to ensure the accuracy of this document, the steering group or any associated NHS Trusts cannot accept responsibility for any errors or omissions in the text. The text is not intended to be totally comprehensive, and the reader should be cognisant of any appropriate drug interactions, adverse effects, contra-indications etc. for antibiotics, as indicated in texts such as the BNF and Summaries of Product Characteristics (SPCs). The clinician is still required to exercise clinical judgement. 9

10 CONTENTS Introduction 1 Urinary Tract Infections: Urinary Tract Infection Uncomplicated 12 Urinary Tract Infections in Pregnancy 15 Higher Urinary Tract Infection or Pyelonephritis 16 Urinary Tract Infection in Children 17 Recurrent Urinary Tract Infection 18 Acute Prostatitis 19 Epididymo-Orchitis 20 Genito-Urinary and Gynaecological Infections: Bacterial Infections Genital Bacterial Vaginosis or Trichomonas 22 Bacterial Infections Genital Pelvic Inflammatory Disease 23 Bacterial Infections Genital Chlamydia, Gonorrhoea and Non-gonococcal Urethritis 24 Genital Viral Infection 25 Genital Yeast infections 27 Respiratory: Community Acquired Pneumonia 28 Acute cough / bronchitis 29 Chronic Obstructive Pulmonary Disease - Acute Exacerbations 29 Bronchiectasis 31 Whooping Cough 32 Bronchiolitis 33 Croup Acute Laryngotracheobronchitis 34 Ear, Nose and Throat: Acute Otitis Media 35 Acute Otitis Externa 37 Dental Infections Simple Gingivitis 39 Dental Infections Acute necrotising Ulcerative Gingivitis and Pericoronitis 40 Dental Infections Dental Abscess 41 Pharyngitis 42 10

11 Oral Candidiasis 44 Sinusitis 45 Skin and soft tissue Infections: Animal & Human bites 46 Bacterial Skin Infection Impetigo / eczema 47 Bacterial Skin Infection Cellulitis and Erysipelas and Insect Bites 49 Cellulitis associated with lymphedema 50 Leg Ulcers 52 Mastitis 53 MRSA Infection 54 MRSA Colonisation 55 Acne 56 Fungal Infections - Skin and Nail 57/8 Parasite Infections Scabies 60 Parasite Infections Head Lice 61 Chicken Pox and Shingles 62 Intra-Abdominal Infections: Enteric and Intra-abdominal Infections 65 C.difficile associated diarrhoea 66 Diverticulitis 67 Cholangitis 68 Miscellaneous: Eye Infections 69 Splenectomy and Infection 70 Antibacterial Prophylaxis Infective endocarditis / Malaria 71 Meningitis 72 Sepsis / Inoculation Incidents 73 Local Contact Details - TB, HIV, Meningococcal Meningitis 75 References and acknowledgements 76 11

12 URINARY TRACT INFECTIONS (UTI) Uncomplicated UTI Give TARGET UTI leaflet N.B Consider back up or delayed antibiotic prescription in all cases Drug Dose Duration Penicillin As antimicrobial resistance and Escherichia coli bacteraemia is increasing, USE NITROFURANTOIN FIRST LINE if appropriate. Always give safety net and self-care advice and consider risk factors for increased resistance which include: care home resident, recurrent UTI (2 in 6 months; 3 in 12 months), hospitalisation >7d in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased resistance, previous UTI resistant to trimethoprim, cephalosporins or quinolones. If increased resistance risk, send culture for susceptibility testing & give safety net advice. All patients 1st line: Nitrofurantoin if GFR 45mls/min MHRA Drug Safety Update: Refer to Page 13 notes If low risk of resistance: Trimethoprim See help note j) To aid compliance: 100mg modifiedrelease (m/r) caps BD (in line with PHE) OR 50mg every 6 hours 200mg BD If 1 st line options unsuitable: If GFR <45mls/min OR high risk of resistance: send urine sample Pivmecillinam 400mg stat then 200mg TDS For 3 days in female patients (treat males for 7 days) For 3 days in female patients (treat males for 7 days) 2 nd Line options: As per MSU specimen sensitivity If only intravenous options remain available the home IV team should be contacted [Tel number: ] 12 Allergy Not applicable Fosfomycin (N.B. Prescribe as brand name Monuril ) Women:3g stat; Men: 2nd 3g dose 3 days later (unlicensed) a) Refer to HPA Diagnosis of UTI Quick Reference Guide for Primary Care April 2011 for further details b) Asymptomatic bacteriuria does NOT generally require treatment; it is common in the elderly, but not associated with increased morbidity. (See separate treatment in pregnancy guidance Page 15) c) Patients over 65: Treat if fever 38 C or 1.5 C above base twice in 12h and dysuria OR 2 other symptoms. d) Treat women with severe/ or 3 symptoms. e) Women with mild/ or 2 symptoms: Pain relief and consider back-up/delayed antibiotic. If urine not cloudy, 97% NPV of no UTI. If urine not cloudy, use dipstick to guide treatment: Nitrite, leucocytes and blood all -ve 76% NPV; nitrite plus blood or leucocytes 92% PPV of UTI. f) Men: Consider prostatitis and send MSU OR if symptoms mild/non-specific, use negative dipstick to exclude UTI. g) For elderly, males, pregnant patients or children, or where there is fever/loin pain always send off an MSU sample. h) For treatment in pregnancy, send MSU for culture & sensitivity and start treatment in line with specific prescribing notes on Page 15. i) In catheterised patients, avoid treatment, unless patient is systemically unwell or pyelonephritis likely. If clinically unwell, consider co-amoxiclav, and send urine for culture. Do not give prophylactic antibiotics for catheter changes unless history of catheterchange-associated UTI or trauma (NICE & SIGN guidance). Take sample if new onset of delirium, or two or more symptoms of UTI. j) Do not use trimethoprim in patients on methotrexate as haematological toxicity can occur. k) Fosfomycin: A further dose may be given 3 days later in women with incomplete resolution of symptoms (unlicensed) where the causative organism has been shown to be fosfomycin-susceptible by culture of urine. l) Fluid promotion and early hydration is very important in all patient groups with UTI ensure adequate fluid and hydration measures are in place.

13 Additional notes: MHRA Drug Safety Update Nitrofurantoin is contraindicated in most patients with an estimated glomerular filtration rate (egfr) of less than 45ml/min/1.73m 2 Nitrofurantoin should not be used to treat sepsis syndrome secondary to UTI s or suspected UTI s Consider checking the renal function when choosing to treat with nitrofurantoin, especially in the elderly A short course (3-7 days) may be used with caution in certain patients with an egfr of 30-44ml/min/1.73m 2. This should only be prescribed to such patients to treat lower UTI with suspected or proven multi-drug resistant pathogens when there is no alternative and the benefits of nitrofurantoin are considered to outweigh the risks of the side effects Closely monitor the patient for signs of pulmonary, hepatic, neurological, haematological and gastro-intestinal side effects during treatment as advised in the SPC The BNF advises to avoid nitrofurantoin at term as it may cause neonatal haemolysis Reference: 1. Medicines and Healthcare products Regulatory Agency (MHRA). Drug Safety Update: Nitrofurantoin is contraindicated in most patients with an estimated glomerular filtration rate (egfr) of less than 45ml/min/1.73m 2 update/nitrofurantoin-now-contraindicated-in-most-patients-with-an-estimated-glomerular-filtration-rate-egfr-of-less-than-45-ml-min-1-73m 2 ; Volume 8, Issue 2; 25 September

14 Additional Notes: U.T.I. Common Pathogens: Escherichia coli. other coliform organisms Staphylococcus saprophyticus Proteus mirabilis 1. 50% of isolates are resistant to amoxicillin, and thus it is no longer suitable for empirical treatment of a UTI. 2. ESBL (Extended-Spectrum Beta-lactamase) producing organisms are becoming increasingly prevalent in the community and resistance patterns are emerging. ESBLs can confer resistance to ciprofloxacin and a broad range of beta-lactam antibiotics including co-amoxiclav. Occasionally ertapenem, a once daily parenteral agent is advised. 3. Isolates are commonly still sensitive to nitrofurantoin (65-85% sensitive), even ESBL producing strains of Gram negative bacteria. Nausea is a common problem with this drug which can be reduced using capsules and/or the modified-release (MR) version. 4. Pivmecillinam is an oral pro-drug of mecillinam, a beta-lactam antibiotic that is active against Gram negative organisms such as Escherichia coli and other enterobacteriaceae. It is not active against Pseudomonas or enterococci. Mecillinam is more active against ESBL producing organisms than other beta-lactams and cephalosporins. As a beta-lactam antibiotic, pivmecillinam should not be prescribed in patients with penicillin allergy; fosfomycin should only be prescribed as an alternative to pivmecillinam in penicillin allergic patients or on the recommendation of consultant microbiologist. 5. The presence of Proteus in the urine may suggest the possibility of renal or bladder calculi. Presence of Staphylococcus aureus may indicate infection higher in the urinary tract. 6. Group B Streptococcus bacteriuria has been reported during pregnancy: treat infection and consider use of peripartum antibiotics. 7. In sterile pyuria, consider urethritis; possible causes: Chlamydia trachomatis, Tuberculosis (TB) or calculi. 8. For men: consider prostatitis and send pre-treatment MSU OR if symptoms mild/non-specific, use ve dipstick to exclude UTI. 9. Nitrofurantoin avoid if egfr less than 45ml/min/1.73m 2. Nitrofurantoin is excreted by the kidneys meaning that impaired renal function may lead to inadequate urine concentrations. There is also a risk of peripheral neuropathy. (see BNF or MHRA Drug Safety Update, Volume 8, Issue 2, September 2014, for further details). Reference: see page 13 for further information on this. 10. In cases of severe renal impairment, please contact the consultant microbiologists for further advice. For patients currently treated by a renal unit, please seek further advice from their consultant renal physician. 11. Quinolones are highly effective, but should never be used routinely, and only with microbiologist advice for complicated infections. Quinolones and cephalosporins have been highly associated with the incidence of Clostridium difficile diarrhoea. 14

15 Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy UTI In pregnancy Nitrofurantoin (see help note e) Refer to page 13 notes reference GFR <45ml/min/1.73m 2 Help Notes 100mg m/r BD For 7 days a) Send MSU for culture and start empirical treatment in all with significant bacteriuria, even if asymptomatic. b) Short term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus. c) Avoid trimethoprim if low folate status or on folate antagonist (e.g. antiepileptic treatment or proguanil) Second Line Drug (s) Drug Dose Duration Trimethoprim (see help notes c) and d). Third Line Drug (s) Cephalosporin i.e. Cefalexin Cefalexin is recommended by PHE as a third line agent if sensitivity indicates for this Amoxicillin (if sensitivities indicate susceptible) 200mg BD 500mg BD 500mg TDS For 7 days For 7 days For 7 days d) Give folic acid if first trimester recommended dose is 5mg OD. e) BNF states to avoid nitrofurantoin at term as it may produce neonatal haemolysis PHE Infection Guidance in Primary Care states that shortterm use of trimethroprim or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus. The PHE guidance quotes the National Teratology Information Service: Trimethroprim is a folate antagonist. In some women low folate levels have been associated with an increased risk of malformations. However, in women with normal folate status, who are well nourished, therapeutic use of trimethroprim for a short period is unlikely to induce folate deficiency. A number of retrospective reviews and case reports indicate that there is no increased risk of foetal toxicity following exposure to nitrofurantoin during pregnancy. Serious adverse reactions e.g. peripheral neuropathy, sever hepatic damage and pulmonary fibrosis are extremely rare. Nitrofurantoin can cause haemolysis in patients with G6PD deficiency. Foetal erythrocytes have little reduced glutathione and there is a theoretical possibility that haemolysis may occur. However, haemolytic disease of the new born has not been reported following in utero exposure to nitrofurantoin. 15

16 Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy Higher UTI or Pyelonephritis in Adults See help note a) for definition of symptoms Co-amoxiclav 625mg TDS For days Ciprofloxacin 500mg BD for 7 days Second Line Drug (s) Drug Dose Duration Ciprofloxacin (as per dosing for penicillin allergy) Use with caution - Clostridium difficile risk Use with caution as risk of C. difficile Help Notes a) Definition Symptoms of higher UTI include: High fever, loin pain, rigors, flank pain, nausea, vomiting and diarrhoea. Symptoms of cystitis may or may not be present. Symptoms develop rapidly over a few hours or a day b) Always obtain an MSU for culture and susceptibility testing and start antibiotics. c) Avoid cefalexin - insufficient activity. d) If no response within 24 hours or if septicaemia is suspected admit to hospital for intravenous (IV) therapy. e) In catheterised patients, avoid treatment, unless patient is systemically unwell or pyelonephritis likely. If clinically unwell, consider co-amoxiclav, and send urine for culture. Do not give prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma (NICE & SIGN guidance). Take sample if new onset of delirium, or two or more symptoms of UTI. f) MRSA in urine is difficult to treat - sensitivity results are essential. Do not treat CSU infections unless prior to surgery or as for note d g) if there is an ESBL risk and upon microbiology advice; consider IV antibiotics via outpatients (OPAT): Outpatient Parenteral Antimicrobial Treatment 16

17 Infection Lower U.T.I. in children Upper UTI In children Trimethoprim Nitrofurantoin If susceptible: Amoxicillin First Line Drug (s) Drug Dose Duration Refer to Children s BNF for dose calculation in paediatrics Second Line Drug (s) 3 days (girls with normal urinary tract anatomy) 7 days (boys or children with abnormal renal tract anatomy) Drug Dose Duration Penicillin Allergy Help Notes a) Confirm infection with MC&S and dipstick. b) Investigation of cause is commonly needed according to age of child. See NICE Clinical Guideline and local paediatric protocols. c) In babies up to 3 months, IV antibiotics are recommended refer immediately d) For children older than 3 months: use positive nitrite to start antibiotics. Send pre-treatment MSU for all. e) Imaging: only refer if child <6 months, recurrent or atypical UTI. f) Repeat samples may be useful if diagnosis is in doubt Co-amoxiclav Refer to children s BNF for dose calculation in paediatrics For 7-10 days 17

18 Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy Recurrent UTI Long term (more than three months at a time) prophylaxis dosing regimens are no longer recommended for recurrent UTI in adult patients. Instead: Discreet treatment doses of antibiotics are recommended for no longer than three months duration followed by a repeat sample for symptomatic episodes. For patients with recurrent UTI, recommend a discrete treatment course of either an empiric or specific agent (if previous MSU/sensitivity results available) and repeat sampling for further symptomatic episodes. If empiric agents are used they should be reviewed in light of any subsequent MSU results and treatment adjusted accordingly. This strategy can help to prevent selection of multi-drug resistant organisms, reducing potential Clostridium difficile infection risk and allows monitoring of organism and resistance profiles against treatment. Prophylaxis treatment is only needed for children: on specialist advice Help Notes a) Also consider standby antibiotics as an alternative. b) Post-coital prophylaxis use recommended drug choices for UTI but as a single stat dose each time after sex (off-label use) c) Recurrent UTI may be due to relapse or re-infection and may occur for a variety of different clinical reasons. d) CKS gives very useful advice on how to manage symptoms in a wide variety of patients. e) Best practice (as outlined in the guidance statement) would be to give discrete treatment courses of either empiric or specific antibiotic agents (based on previous MSU/sensitivity results available), with repeat sampling for repeat episodes, rather than single agent prolonged prophylaxis/treatment. This strategy can help to prevent selection of antibiotic resistant organisms and reduce the potential C.difficile infection risk. f) For patients in whom antibiotic prophylaxis has already been (historically) instituted, the guidelines DO NOT recommend discontinuation of their on-going prophylaxis. It would be clinically prudent, however, to review the need for prophylaxis and the agent being used (which should include some degree of repeat sampling to assess agent effectiveness against organisms cultured). g) For patients who are not on prophylaxis for recurrent UTI, but for whom the clinician feels there would be benefit to commencing an agent for prolonged treatment (i.e. not low dose/half dose); the guidelines DO NOT prohibit their use, but do guide that they should not be used for greater than 3 months in any given period. Certainly the clinician should undertake sampling at 3 months (if not before) to assess ongoing effectiveness of the agent being used. 18

19 Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy Help Notes Acute Prostatitis Ciprofloxacin 500mg BD For 28 days a) Send MSU for culture and sensitivity. Second Line Drug (s) Drug Dose Duration Ofloxacin 200mg BD For 28 days Alternative If Above Not Tolerated Drug Dose Duration Trimethoprim 200mg BD 28 days Additional Notes Common Pathogens: E.coli. Gram negative bacilli Enterobacter spp. Clinical Details: 1. Prostatic tissues are best penetrated by drugs with a high pka and high lipid solubility, such as quinolones. 2. Empiric treatment is common, but gonorrhoea and chlamydia should be excluded. 3. Late relapse (6-12 months after treatment) is common. b) Consider an STD, send urine for chlamydia PCR. c) Most infections are caused by Gram negative bacteria. d) Chronic bacterial prostatitis may require 4-6 weeks treatment refer to NICE/CKS guidance e) Refer all patients with STD s to GUM clinic f) NB risk of C difficile disease with quinolones. Stop immediately if diarrhoea occurs. In patients at high risk of, or previous, C difficile disease use an alternative agent. 19

20 Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy Epididymo- Orchitis In cases where aetiology most probably due to STI e.g. chlamydia N.B. Refer high risk gonorrhoea patients to the GUM clinic - see help notes f) and g) and Refer page 21 for contact details In cases where aetiology most probably due to enteric organisms N.B. Refer high risk gonorrhoea patients to the GUM clinic - see help notes f) and g) and Refer page 21 for contact details Help Notes Doxycycline 100mg BD For 10 days a) In males <35 years, often caused by STI such as Chlamydia if suspected, advise to abstain from intercourse until treatment finished. Suggest partner is screened and treated. b) In males >35 years, often caused by non-sexually OR Ofloxacin 200mg BD For 14 days Relevant investigations: MSU and urine for chlamydia PCR and urethral swab for N. gonorrhoea culture if clinically indicated N.B If there is suspicion of an STD refer the patient to the GUM clinic for treatment - see help note (h) First Line Drug (s) Drug Dose Duration Ofloxacin 200mg BD For 14 days Relevant investigations: MSU and urine for chlamydia PCR and urethral swab for N. gonorrhoea culture if clinically indicated N.B If there is suspicion of an STD refer the patient to the GUM clinic for treatment - see help note (h) transmitted, Gram negative enteric organisms that cause UTIs, however crossover between both groups occurs. If N. gonorrhoea is isolated, contact GUM Clinic. Refer to page 21 for contact details. c) In all cases- testicular torsion should be considered as a differential diagnosis especially in patients under 20 (although this can occur at any age) presenting with acute onset severe pain this requires urgent surgical referral. d) Consider mumps in non-immunised adults born between with history of headache, fever and unilateral/bilateral parotid swelling 7-10 days prior to testicular swelling. Antibiotics not indicated. e) In all cases consider general support measures such as scrotal elevation (good supporting underwear), analgesia and bed rest. f) Common risk factors for gonorrhoea are: previous N. gonorrhoeae infection; known contact of gonorrhoea; presence of purulent urethral discharge, men who have sex with men and black ethnicity g) Refer high risk gonorrhoea patients to the GUM clinic for treatment with IM ceftriaxone 500mg stat. These high risk patients must receive oral therapy as indicated in the guideline AND be referred for IM ceftriaxone treatment in the GUM clinic AS WELL. Refer to page 21 for contact details. Clinical care pathway for management of epidiymo-orchitis produced by BASSH is available: Reference: 20

21 Additional Notes: Epididymo-orchitis National guidelines produced by BASHH (British Association for Sexual Health and HIV) for the management of epididymo-orchitis make the following statements regarding the aetiology of acute epididymo-orchitis in relation to patient age. Under 35 years - most often a sexually transmitted pathogen such as Chlamydia trachomatis and Neisseria gonorrhoeae. Over 35 years - most often non-sexually transmitted Gram negative enteric organisms causing urinary tract infections. Particular risks include recent instrumentation or catheterisation. However the guidelines also state that: There is crossover between these groups and complete sexual history taking is imperative. In light of this, if there is clinical concern of an STI in a patient >35years of age presenting with symptoms of acute epididymoorchitis, they should be treated accordingly Reference: GUM CLINIC CONTACT TELEPHONE NUMBERS John Anthony Centre, Newtown Road, Worcester, WR5 1JF. Tel: Arrowside, Alexandra Hospital Site, Woodrow Drive, Redditch, Worcestershire B98 7UB. Tel:

22 GENITO-URINARY AND GYNAECOLOGICAL INFECTIONS Infection First Line Drug (s) Penicillin Allergy Drug Dose Duration Bacterial Vaginosis Trichomonas Metronidazole 400mg BD For 7 days OR Metronidazole 2 grams Single dose First Line Drug (s) Drug Dose Duration Metronidazole 400mg BD For 7 days Metronidazole 2 grams Single dose In pregnancy/breastfeeding: avoid 2g stat dose. Refer to GUM. Consider clotrimazole 100mg pessary at night for 6 nights for symptom relief (not cure) if metronidazole declined. Refer to GUM page 21 contact details. Help Notes a) History of vaginal discharge with odour (typically fishy) and raised ph of vaginal fluid very suggestive of infection. Diagnosis may be based on swab or if at low risk of STI, patients with relevant symptoms may be treated empirically without investigation b) Oral metronidazole is as effective as topical treatment and more cost effective. There is less relapse with 7 days treatment than 2g stat at 4 weeks. c) For those intolerant to metronidazole use clindamycin vaginal cream. d) For bacterial vaginosis in pregnancy, avoid 2g dose, treat with oral metronidazole 400mg bd for 7 days as early as possible in the 2nd trimester. (There is no evidence of teratogenicity in humans when used at this dose). e) Group B strep is normal flora in the vagina and when isolated in an HVS does not require treatment, however when isolated in pregnancy peri-partum antibiotics should be considered. Ensure patients are aware of risks and notes annotated accordingly, and appropriate advice leaflet given (see RCOG website) f) Trichomonas is a sexually transmitted infection, consider contact tracing. Treat partners and refer to GUM clinic. g) Consider HIV or syphilis testing in all cases of STD. h) There is evidence suggesting that the use of acetic acid is effective for the treatment of bacterial vaginosis as well although dosing schedules are not provided within the scope of this guideline. 22

23 Infection First Line Drug (s) Penicillin Allergy Drug Dose Duration Pelvic Inflammatory Disease Refer high risk gonorrhoea patients to the GUM clinic see help note f) and g) These high risk patients must receive oral therapy as indicated in the guideline AND be referred for IM ceftriaxone treatment in the GUM clinic AS WELL. Refer page 21 contact details Chlamydia N.B doses differ in pregnant patients, refer to help note c) Ofloxacin AND Metronidazole 400mg BD 400mg BD For 14 days For 14 days Help Notes a) In cases of suspected PID, always test for gonorrhoea and Chlamydia. b) If treatment failure in P.I.D. reassesses diagnosis and antibiotic compliance, consider referral to Gynaecology clinic. c) Consider admission if systemically unwell. d) In pregnancy, seek specialist advice. e) Partners of index patients diagnosed with PID should be offered anti-chlamydial treatment empirically. f) 28% of gonorrhoea isolates now resistant to quinolones. If gonorrhoea likely (partner has it, severe symptoms, sex abroad) refer to GUM- avoid treatment with ofloxacin g) Common risk factors for gonorrhoea are: previous N. gonorrhoeae infection; known contact of gonorrhoea; presence of purulent urethral discharge, men who have sex with men and black ethnicity Refer high risk gonorrhoea patients to the GUM clinic -see help note f) and g). Refer page 21 for contact details Azithromycin 1 gram Single dose a) Contact tracing and treatment is an important issue. b) STDs often co-exist with other infections. OR c) In pregnancy, azithromycin 1g stat (unlicensed use in Doxycycline (this 100mg BD For 7 days UK) is the most effective option or erythromycin 500mg qds is preferred for for 7 days or amoxicillin 500mg tds for 7 days should be used. Due to low cure rate in pregnancy, test for cure 6 rectal chlamydia) weeks after treatment. If treatment failure, refer to GUM OR (Alternative regimens) clinic. d) Patients should be advised to avoid sexual intercourse Erythromycin 500mg BD For 14 days (including oral sex) until they and their partner(s) have OR completed treatment (or wait 7 days if treated with Ofloxacin 200mg BD For 7 days azithromycin) OR N.B Relevant investigations in all cases: 400mg OD MSU and urine for chlamydia PCR and urethral swab for N. gonorrhoea culture if clinically indicated 23

24 Infection First Line Drug (s) Penicillin Allergy Drug Dose Duration Gonorrhoea Non-gonococcal urethritis (NGU) Refer high risk gonorrhoea patients to the GUM clinic see help note b) and c) These high risk patients must receive oral therapy as indicated in the guideline AND be referred for IM ceftriaxone treatment in the GUM clinic AS WELL. Refer page 21 contact details REFER ALL PATIENTS TO GUM CLINIC refer to page 21 for contact details. See help note a) Azithromycin 1 gram Single dose For recurrent infection: Azithromycin AND Metronidazole 500mg stat then 250mg for the next four days 400mg BD for 5 days Help Notes a) PLEASE NOTE: Department of Health guidance: Gonorrhoea and Antimicrobial Resistance H-CMO-CPO-letter.pdf b) Treatment for recurrent infection should include cover for Mycoplasma genitalium and Trichomonas vaginalis c) Common risk factors for gonorrhoea are: previous N. gonorrhoeae infection; known contact of gonorrhoea; presence of purulent urethral discharge, men who have sex with men and black ethnicity d) Refer high risk gonorrhoea patients and patients with gonorrhoea to the GUM clinic. Refer page 21 contact details 24

25 Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy Primary Herpes simplex (Type 1 or 2) Aciclovir 200mg 5 times daily Help Notes For 5 days a) Depending on severity, a topical analgesic (e.g. lidocaine 2%) can be prescribed. Discuss other measures for pain relief - oral analgesics and daily soaks/baths in saline solution. b) Watch out for secondary bacterial infection. STDs commonly co-exist, & therefore refer to GUM for new presentations. c) Syphilis testing should be offered in all patients with genital ulceration. d) Patients are advised to avoid sexual intercourse until lesions have healed. e) In all cases of HSV in pregnancy, seek advice for details of management. f) In difficult cases seek GUM advice. g) Explanations as regards latency of infection should be offered with GUM referral if further counselling required. Mild recurrences Infrequent severe recurrences Frequent severe recurrences (more than six episodes a year) Manage symptomatically Treat each occurrence with five days aciclovir as above Aciclovir 400mg BD for 6-12 months ( review 3 monthly) 25

26 Infection First Line Drug (s) Penicillin Allergy Drug Dose Duration Genital yeast infections Treatment for NON-PREGNANT PATIENTS PO Fluconazole N.B DO NOT prescribe PO fluconazole if pregnant or possibly pregnant Refer page 27 for treatment of pregnant patients 150mg Single dose Help Notes a) If the vulva is very inflamed topical treatment may be painful use oral fluconazole. Avoid perfumed soap and shower gels. Topical clotrimazole HC cream bd may alleviate symptoms. b) Recurrent vaginal infections may suggest possible underlying pathology e.g. diabetes. Take a swab to confirm diagnosis and assess antifungal susceptibility of any Candida isolated. See CKS guidance for further information on the management of vaginal discharge. Avoid antibiotic therapy where possible as it may precipitate candidiasis. c) For penile candidiasis use 1% clotrimazole topical cream. d) Clotrimazole pessaries and cream (but not HC version) and fluconazole capsules can be purchased from community pharmacies. OR Clotrimazole pessary OR Clotrimazole 10% vaginal cream 500mg 5 grams Single application Single application 26

27 Infection First Line Drug (s) Penicillin Allergy Drug Dose Duration Genital yeast infections Treatment for PREGNANT PATIENTS Clotrimazole Pessary N.B can be prescribed in pregnancy 100mg pessary at night 6 nights pregnant patients Help Notes OR Miconazole 2% cream N.B can be prescribed in pregnancy 5g intravaginally BD 7 days pregnant patients 27

28 RESPIRATORY Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy Community Acquired Pneumonia Manage using clinical judgment and modified CRB-65 score as follows (each scores 1): Mild infection (CRB-65 score 0) Suitable for home treatment Amoxicillin 500mg TDS For 5 days Clarithromycin 500mg BD for 5 days OR Doxycycline 200mg stat then 100mg od for 5 days Help Notes a) If pneumonia is suspected, pneumococci account for 70+% of cases. In Worcestershire penicillin resistance in pneumococci is extremely rare. b) If an atypical pneumonia is strongly suspected, then clarithromycin would be 1st choice. Confusion (AMT <8) Respiratory rate >30/min BP systolic <90mmHg diastolic <60 Age >65 years Moderate infection (CRB-65 score 1 or 2) Hospital Assessment or admission Amoxicillin 500mg TDS 7 days AND Clarithromycin 500mg BD 7 days OR Doxycycline 200mg stat then 100mg OD for 7 days as a single agent Severe infection (CRB-65 score 3+) Urgent Hospital admission Doxycycline 200mg stat then 100mg od for 7 days 28

29 Infection First Line Drug (s) Penicillin Drug Dose Duration Allergy Acute Cough / Bronchitis For all patients: Consider 7-14 day delayed antibiotic with symptomatic advice/leaflet See help note d) for further advice Amoxicillin OR 500mg TDS For 5 days Doxycycline 200mg stat Doxycycline 200mg stat then then 100mg OD For 5 days 100mg od for 5 days Help Notes a) Antibiotic is of little benefit if no co-morbidity. b) Consider immediate antibiotics if >80 years and ONE of: hospitalisation in the past year, oral steroids, diabetic, congestive heart failure, OR >65 years with 2 of the above. c) Symptom resolution can take 3 weeks. Most H. influenza strains are resistant to erythromycin, therefore not advised in this condition. d) N.B CRP levels can be used to guide treatment when considering if antibiotic prescription is indicated or not although definitive criteria and guidance on when to issue a prescription or defer issue with the use of CRP testing apparatus is not provided within the scope of this guidance. C.O.P.D. Acute Exacerbations Many acute infective exacerbations are viral, and do not require antibiotics See help notes a) b) and c) First Line Drug (s) Drug Dose Duration Amoxicllin 500mg TDS For 7 days OR Doxycycline 200mg STAT THEN 100mg OD For 7 days Second Line Drug (s) Drug Dose Duration Clarithromycin 500mg BD For 7 days If resistance risk factors: see help note g): Co-amoxiclav* 625mg TDS For 7 days *Ensure positive sputum sample result before prescribing Doxycycline 200mg stat then 100mg od for 5-7 days OR Clarithromycin 500mg BD for 5-7 days a) Many acute infective exacerbations are viral, and do not require antibiotics. b) Patients with recurrent infections will require longer courses, and sputum cultures should be taken. c) Consider standby home packs of 1 st line antibiotics and oral steroids, if indicated, for appropriate patients. d) COPD patients require single pneumococcal vaccination and annual influenza vaccination. e) In some circumstances more than 7 days treatment may be needed, particularly in patients with features of bronchiectasis. f) Treat exacerbations promptly with antibiotics if purulent sputum and increased SOB and/or increased sputum volume. g) Risk factors for antibiotic resistant organisms include: co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months 29

30 Additional Notes: Respiratory Tract Infection Common Pathogens: Haemophilus influenzae Streptococcus pneumoniae Moraxella catarrhalis Atypical - Mycoplasma pneumoniae, Legionella pneumophilia Clinical Details: 1. Use of beta-lactam antibiotics - amoxicillin remains the treatment of choice in patients not allergic to penicillins, as resistance in pneumococci is very rare locally, and most strains of H. influenzae are also sensitive. Question carefully about penicillin allergy to validate it. Coamoxiclav is active against beta-lactamase producing organisims but does not cover penicillin-resistant pneumococci. 2. Uses of macrolides - erythromycin, clarithromycin and azithromycin all have a similar spectrum of activity, and resistance to one usually indicates resistance to all these compounds. Resistance in pneumococci is uncommon, but some H. influenzae strains are less susceptible. 3. Use of cephalosporins (e.g. cefalexin) inappropriate as oral agents for chest infections (insufficient activity against Haemophilus sp), also increased risk of C.difficile disease. 4. Use of quinolones Not generally advised due to risk of C.difficile disease. Ciprofloxacin & ofloxacin are not reliably effective against pneumococci, and should not be used to treat primary pneumonias. Quinolones penetrate into lung tissue well, and are thus useful in treating difficult cases of COPD and bronchiectasis. They are not licensed for use in children or in pregnancy, although ciprofloxacin has been used extensively in paediatric cystic fibrosis. Moxifloxacin is more effective against pneumococci, this may be occasionally prescribed if no suitable alternative available. 5. Use of tetracyclines - there is little difference in activity for various tetracyclines. Most of the atypical organisms are sensitive, as are a majority of the pneumococci and Haemophilus influenzae isolates. Tetracyclines are bacteriostatic, and as they cannot be used in children or pregnancy, their role is limited to less severe infections in adults. 6. Consider Pneumococcal and influenza vaccines in at risk cases (see annual CMO letter and HMSO Publication Immunisations against Infectious Diseases. 30